1. Management of the Patient Presenting with Wide Complex Tachycardia
Samir Saba, MD
Director, Cardiac Electrophysiology

2. Definition
Heart rate > 100 b/min
QRS > 120 ms

3. Differential Diagnosis
Supraventricular tachycardia with aberrancy
Pre-excited tachycardia
Motion artifact
Paced rhythm
Ventricular tachycardia
Idiopathic
Non-idiopathic

4. Importance of diagnosing VT
Sensitivity versus Specificity
In all patients with WCT, VT is the diagnosis in 80% of cases

5. SVT with aberrancy
Typical RBBB
Typical LBBB

6. Typical bundle morphology
LBBB
RBBB

7. LBBB in AVRT

8. RBBB and AVRT

9. Pre-excited Tachycardia
Manifest versus concealed AP

10. WPW

11. WPW

12. Antidromic AVRT

13. Atrial Flutter with Preexcitation

14. AF with Preexcitation

15. Motion artifact Failure to recognize artifact is common:
94% of internists
58% of cardiologists
38% of EP

16. Motion Artifact Recognize artifact by:
Marching the high frequency signal across the WCT
Looking at other available leads

17. Paced ECG

18. Paced ECG
Paced
Not Paced

19. Ventricular Tachycardia
Idiopathic
RVOT VT
LVOT VT
Lt fascicular VT
Non-idiopathic
ICM
NICM
HCM
Channelopathy (LQTS, Brugada, etc…)

20. RVOT VT

21. LVOT VT

22. Left fascicular VT

23. Other Classifications for VT
Morphology:
Monomorphic
Polymorphic
Bidirectional
Mechanisms:
Reentry
Automaticity
Triggered activity
Drug susceptibility:
Verapamil sensitive
Adenosine sensitive

24. Repetitive VT

25. MMVT

26. Non-idiopathic VT

27. Ventricular Tachycardia

28. Bidirectional VT

29. Mechanisms of VT

30. Approach to Management
History
Physical Exam
ECG
EP Study

31. History Age (if >35 yrs, VT>85%)
Symptoms (palpitations, syncope, LH, diaphoresis, angina, seizures, CA…)
Circumstances: N/V/D (electrolytes)
PMH: Cardiac disease, MI, CHF, ICD, RF
Family history: SCD, arrhythmias
Medications: QT prolongation, digoxin, diuretics, etc…
Habits: Drugs

32. Physical Examination Hemodynamic Stability Signs of acute CHF
Sternal wound
PVD
Stroke
PM/ICD
Evidence of AV dissociation (cannon A waves, marked fluctuations in BP, variable S1 intensity)
Maneuvers: CSM, pharmacologic interventions (lidocaine, adenosine, BB, verapamil)

33. Other tests
Laboratory tests: K, Mg, plasma concentrations of drugs (dig, procan, etc…)
CXR: cardiomegaly
Echo: structural abnormalities

34. ECG In NSR: AV dissociation Ischemia Fusion beats Acute MI
During WCT:
AV dissociation
Fusion beats
Capture beats
Morphology
Width of QRS
Morphology of the bundles
Electrical axis
Precordial concordance
In NSR:
Ischemia
Acute MI
Old MI
Long QT
Brugada pattern
LVH
Epsilon waves

35. AV dissociation

36. Fusion beat

37. ECG

38. ECG

39. Therapy Acute Management: For the Unstable patient:
Emergent synchronized cardioversion
If QRS and T cannot be distinguished then defibrillation
Cautious use of sedatives and analgesics
For the Stable patient:
Class I or III AAD
Treatment of associated conditions (ischemia, electrolytes,…)
Elective cardioversion
Interrogation of ICD or PM if present

40. Therapy Chronic Management: AAD: EPS+/-RFA ICD
class IC or III, if structurally normal hearts
class III, if structurally abnormal hearts (with ICD)
EPS+/-RFA
Stand alone therapy in idiopathic VT
Adjunctive therapy (+/-AAD) in ischemic VT
ICD
For primary and secondary prevention of SCD

41. Indication for EPS

42. EP Study
Induce the arrhythmia
Activation or Pace mapping
Ablation

43. Activation Map for VT

44. RVOT VT: pace map

45. Special Case: NSVT EF≤35%, then ICD EF>40%, no ICD
35%<EF≤40%, then EPS and ICD if EPS+ (MUSTT trial)
In all these cases, -blockers and other AAD can be used if NSVT is symptomatic.

46. Summary
DDX of WCT includes VT, SVT with aberrancy, preexcited tachycardia, artifact, and paced rhythm. VT accounts for 80%
Diagnosis hinges of good history, PE, ECG
Acute management depends on stability of patient. In the unstable patient, immediate cardioversion or defibrillation is recommended
Long term management armamentarium includes: AAD, Ablation, ICD

47. Holter Monitor in a Mouse

48. EPS in a Mouse

49. Question?…